M.S. Program in Clinical-Counseling Psychology
Preregistration Practicum Approval Form
(This form must be completed one month prior to the end of the semester prior to practicum and submitted to the Program Coordinator)


 

Studentís name:______________________________

 
VSU Faculty Supervisor (Practicum course instructor):___________________________


VSU Advisor:______________________________

Studentís Phone: Home:_____________________Work:_______________________


Studentís email address:__________________________________________


Semester of Practicum: term:________ year:________

Has the practicum site been previously approved?   YES   NO


 

Practicum Site name:__________________________________________


 

Site Address:___________________________________________________________


 

On-Site Supervisor: _______________________Phone: (____)_________________


 

Qualifications of Supervisor (degree, license):__________________________________

Type of Clientele (incl. age range):___________________________________________


 

Activities Available (e.g., type of testing, group/ind. couns.): ______________________


 

________________________________________________________________________


 

Type of liability insurance (attach photocopy):_______________________


 

Term Prepracticum was completed with grade of B or better: term:________ year:________


 

Term Comprehensive Exams were successfully completed: term:________ year:________


 

_____________________________________ ____________________________________
Signature of Student
Signature of Advisor